Background: Recycling transplanted kidneys, in other words using an allograft which has previously been transplanted in one recipient for transplant in a second recipient, can be a source of opportunity for expanding the pool of available grafts in the USA and beyond. Summary: We describe a case of renal transplantation from a donor who had undergone a kidney transplant 3 years prior and had good graft function at the time of procurement. The recipient underwent transplantation uneventfully and to date has demonstrated excellent graft function. We also include a literature review of reported cases of recycled/retransplanted kidneys. Key Messages: Recycling transplanted kidneys is a largely untapped resource which could help decrease the transplant waitlist. Utilizing such kidneys does need special considerations in terms of procurement technique, back table, crossmatch, recipient selection, and follow-up.

The demand for kidney transplantation continues to grow globally, as kidney disease affects a larger number of people. However, the supply of available kidneys for transplantation has not kept up with the increasing demand, leading to a significant shortage of organs for transplantation. The shortage of available kidneys has been an ongoing issue for the transplant community, resulting in long wait times, increased morbidity and mortality rates, and higher healthcare costs.

According to the Organ Procurement and Transplantation Network (OPTN), there are currently almost 100,000 people in the USA waiting for a kidney transplant, while only about 25,000 kidneys are transplanted each year [1]. This results in a significant gap between the number of people in need of a transplant and the number of available kidneys. This directly translates to 5,000 deaths among patients awaiting renal transplantation every year.

This paper aimed to explore a possible source of kidneys that are opted to not be used at transplant centers. Estimated 20–30% of kidney grafts are discarded in the USA annually, around 2,700 kidneys, which may otherwise be used for transplantation [2]. Multicenter studies which compare discarded kidneys in the USA to similar kidneys chosen for transplantation in Europe demonstrate that kidneys with the same donor and recipient attributes as well as histological findings have acceptable allograft survival. This represents lost opportunity for increasing donor pool in the USA [3]. Reusing transplanted kidneys, in other words using a graft which is already been transplanted in one recipient for transplant in a second recipient, can be a source of opportunity in expanding the pool of available grafts in the USA and beyond. We describe a case of renal transplantation from a donor who had himself received the transplant 3 years prior and had good graft function at the time of procurement. The recipient underwent transplantation uneventfully and to date has demonstrated excellent graft function. We also include a literature review. The Introduction should provide a summary of the background to the relevant field of research and the specific problems addressed and should state the hypotheses being explored as well as the main goal(s) of the study. Conclusions or findings should not appear in the Introduction.

A comprehensive literature search was conducted to identify case reports on reused or transplanted kidney. The following electronic databases were searched: PubMed, Embase, Scopus, and Web of Science. The search was limited to articles published in English prior to May 2022. The following search terms were used: “reused kidney transplant” and “kidney retransplantation.”

Inclusion and Exclusion Criteria

The identified studies were screened based on predefined inclusion and exclusion criteria. Case reports that described the reuse of a previously transplanted kidney or reported on the outcomes of kidney transplant recipients who underwent retransplantation were included. Studies that focused on other organs or non-transplant-related topics were excluded. In addition, studies published in languages other than English or those that lacked sufficient information regarding the reuse or retransplantation of kidneys were also excluded.

Data Extraction

Data from the included case reports were extracted using a standardized form. The following information was collected: author(s), publication year, country, study design, number of patients, patient characteristics (e.g., age, gender), original transplant details (e.g., donor source, immunosuppressive regimen), reasons for retransplantation or reuse, interval between the original transplant and retransplantation, surgical technique, perioperative complications, graft function and survival, immunosuppressive management, and long-term outcomes.

Data Analysis

The extracted data were analyzed descriptively. The characteristics of the included case reports are summarized in Table 1. The demographic and clinical characteristics of the patients, as well as the outcomes and complications related to the reused or retransplanted kidneys, were reported. Common themes and patterns were identified and discussed in the context of existing literature.

Table 1.

Donor and recipient characteristics and outcomes in reported cases of kidney retransplantation

ArticlePrimary donor age/sexPrimary donor cause of deathSecondary donor age/sexLength of graft functionSecondary donor cause of death/creatinine at time of explanationTerminal Cr, mg/dLFinal recipient age/sexFinal recipient cause of kidney diseaseFollow-up/survival data of recipient
Ghinea et al. [4] (2021) N/A 46/F 9 years Spontaneous intracranial hemorrhage 0.8 51/M Polycystic kidney disease 4 years; living; functional graft 
Kadambi et al. [5] (2012) 18/M Blunt force trauma to the head causing an intracranial bleed 38/F Spontaneous intracranial hemorrhage 1.2 42/M Hypertension 5 years; living; functional graft 
Hamroun et al. [6] (2021) 32/M N/A 23/M 8 months FSGS recurrence with persistent nephrotic syndrome; patient requested transplant nephrectomy 78/M Bilateral nephrectomy due to renal cell carcinoma 
Yıldız et al. [7] (2016) 41/M Cerebral hemorrhage after traffic accident 50/M 6 years Intracranial hemorrhage 1.2 24/M Chronic glomerulonephritis 3 years; living; functional graft 
Goralczyk et al. [8] (2010) 36/F Spontaneous subarachnoid hemorrhage 32/M 2 years Severe grand mal seizure with brain edema 66/F Chronic glomerulonephritis 14 years; living; functional graft 
Setyapranata et al. [9] (2015) Cerebral hypoxia 9 days Myocardial infarction with cardiac arrest leading to brain death 68/M Reflux nephropathy 3 years; living; functional graft 
Lugo-Baruqui et al. [10] (2015) 25/M Cerebral hemorrhage 5 years and 5 months Cerebrovascular hemorrhage 60/F Hypertensive nephrosclerosis 
Tseng et al. [11] (2018) 40/M Intracranial hemorrhage due to traffic accident 45/M 9 years Intracranial hemorrhage 0.94 40/M Diabetic nephropathy 10 years; living; functional graft 
Park et al. [12] (2014) 43/M Intracranial hemorrhage 55/F 2 years Cardiac arrest with brain hypoxia 1.68 65/M Diabetic nephropathy 4 years; living; functional graft 
Andrés et al. [13] (1993) 22/M Brain death due to intracranial hemorrhage 39/M 8 days Intracranial hemorrhage 39/M Chronic glomerulonephritis 6 months; living; functional graft 
Veale et al. [14] (2018) 29/F Brain death 55/F 12 days Stroke with functioning liver and kidney grafts 0.7 58/F Polycystic kidney disease 2 months; living; functional graft 
Karakizlis et al. [15] (2022) 36/F Cerebral vascular aneurysm 43/M 2 years Cerebral vascular aneurysm 1.5 65 18 years; living; functional graft 
Karakizlis et al. [15] (2022) 54/M Cerebral vascular aneurysm 61/F 2 months Cerebral vascular aneurysm 1.5 65 10 years and 5 months; living; functional graft 
Karakizlis et al. [15] (2022) 18/M Suicide (head injury) 32/F 5 years Cerebral vascular aneurysm 1.3 65 8 years and 4 months; living; functional graft 
Karakizlis et al. [15] (2022) 20/M Polytrauma 59/F 9 years Cerebral infarction 67 3 years; living; functional graft 
Kamar et al. [16] (2008) 34/F 1.25 months Idiopathic thrombotic microangiopathy 54/F Polycystic kidney disease 6 months; living; functional graft 
Bryan et al. [17] (2010) 40/F 7 months Anoxia 0.8 N/A 10 months; living; functional graft 
ArticlePrimary donor age/sexPrimary donor cause of deathSecondary donor age/sexLength of graft functionSecondary donor cause of death/creatinine at time of explanationTerminal Cr, mg/dLFinal recipient age/sexFinal recipient cause of kidney diseaseFollow-up/survival data of recipient
Ghinea et al. [4] (2021) N/A 46/F 9 years Spontaneous intracranial hemorrhage 0.8 51/M Polycystic kidney disease 4 years; living; functional graft 
Kadambi et al. [5] (2012) 18/M Blunt force trauma to the head causing an intracranial bleed 38/F Spontaneous intracranial hemorrhage 1.2 42/M Hypertension 5 years; living; functional graft 
Hamroun et al. [6] (2021) 32/M N/A 23/M 8 months FSGS recurrence with persistent nephrotic syndrome; patient requested transplant nephrectomy 78/M Bilateral nephrectomy due to renal cell carcinoma 
Yıldız et al. [7] (2016) 41/M Cerebral hemorrhage after traffic accident 50/M 6 years Intracranial hemorrhage 1.2 24/M Chronic glomerulonephritis 3 years; living; functional graft 
Goralczyk et al. [8] (2010) 36/F Spontaneous subarachnoid hemorrhage 32/M 2 years Severe grand mal seizure with brain edema 66/F Chronic glomerulonephritis 14 years; living; functional graft 
Setyapranata et al. [9] (2015) Cerebral hypoxia 9 days Myocardial infarction with cardiac arrest leading to brain death 68/M Reflux nephropathy 3 years; living; functional graft 
Lugo-Baruqui et al. [10] (2015) 25/M Cerebral hemorrhage 5 years and 5 months Cerebrovascular hemorrhage 60/F Hypertensive nephrosclerosis 
Tseng et al. [11] (2018) 40/M Intracranial hemorrhage due to traffic accident 45/M 9 years Intracranial hemorrhage 0.94 40/M Diabetic nephropathy 10 years; living; functional graft 
Park et al. [12] (2014) 43/M Intracranial hemorrhage 55/F 2 years Cardiac arrest with brain hypoxia 1.68 65/M Diabetic nephropathy 4 years; living; functional graft 
Andrés et al. [13] (1993) 22/M Brain death due to intracranial hemorrhage 39/M 8 days Intracranial hemorrhage 39/M Chronic glomerulonephritis 6 months; living; functional graft 
Veale et al. [14] (2018) 29/F Brain death 55/F 12 days Stroke with functioning liver and kidney grafts 0.7 58/F Polycystic kidney disease 2 months; living; functional graft 
Karakizlis et al. [15] (2022) 36/F Cerebral vascular aneurysm 43/M 2 years Cerebral vascular aneurysm 1.5 65 18 years; living; functional graft 
Karakizlis et al. [15] (2022) 54/M Cerebral vascular aneurysm 61/F 2 months Cerebral vascular aneurysm 1.5 65 10 years and 5 months; living; functional graft 
Karakizlis et al. [15] (2022) 18/M Suicide (head injury) 32/F 5 years Cerebral vascular aneurysm 1.3 65 8 years and 4 months; living; functional graft 
Karakizlis et al. [15] (2022) 20/M Polytrauma 59/F 9 years Cerebral infarction 67 3 years; living; functional graft 
Kamar et al. [16] (2008) 34/F 1.25 months Idiopathic thrombotic microangiopathy 54/F Polycystic kidney disease 6 months; living; functional graft 
Bryan et al. [17] (2010) 40/F 7 months Anoxia 0.8 N/A 10 months; living; functional graft 

Case Report

Donor

The donor to our recipient (secondary donor/primary recipient in this case) was a 51-year-old male who progressed to brain death after a hemorrhagic stroke. He had a prior history of end-stage renal disease secondary to type 1 diabetes mellitus and underwent simultaneous kidney and pancreas transplantation 3 years ago. Patient also had a history of coronary artery disease and congestive heart failure with preserved ejection fraction. The kidney donor profile index (KDPI) of the kidney was 94%. Blood urea nitrogen/creatinine at admission was 13/1.23, peak of 20/1.76 and terminal of 15/1.12. This donor was not on insulin and had a normal HbA1c of 5.5%. He was anti-HepBc Ab positive, and Hep BsAg and HBV DNA were negative. No history of rejection, infection, or previous graft function was available from this donor.

The primary donor was a 14-year-old male who progressed to brain death after GSW to the head, KDPI-11%, terminal blood urea nitrogen/creatinine being 10/0.46. The donor’s HbA1c was 5.4%, amylase/lipase being 54/26, respectively. The left donor kidney and pancreas from this donor were transplanted. The kidney had single vessels and single ureter. The pancreas allograft was procured and transplanted in the standard manner and was enteric drained.

During procurement of this kidney, the contralateral iliac artery was cannulated to flush the transplanted kidney adequately. The kidney was procured en bloc with the right common and external iliac artery and vein, and the ureter was procured with a bladder cuff (Fig. 1). A preimplantation wedge kidney biopsy was done from the donor kidney which showed 5% glomerulosclerosis with mild interstitial fibrosis and no vascular changes.

Fig. 1.

Kidney after procurement. Black arrow – prior venous anastomosis. Yellow arrow – donor iliac artery. Green arrow – bladder cuff.

Fig. 1.

Kidney after procurement. Black arrow – prior venous anastomosis. Yellow arrow – donor iliac artery. Green arrow – bladder cuff.

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Recipient

Recipient was a 71-year-old male with medical history of hypertension, type 2 diabetes mellitus, coronary artery disease status post-CABG, hyperlipidemia, hypothyroidism, and history of urolithiasis who had end-stage renal disease secondary to hypertensive nephrosclerosis. He was on daily peritoneal dialysis, HLA mismatch 2, 2, 0/EPTS: 71/CPRA: 0. The HLA profiles of the primary and secondary donor were available. A virtual crossmatch was done with both donors and was negative and acceptable. The donor kidney was meticulously dissected on the back table (Fig. 2). The donor renal artery and vein were dissected and separated from the donor iliac vessels. The risks and benefits of this transplant were discussed in detail with the patient, the recipient was concerned about the high KDPI of the donor, we discussed how the KDPI of the original donor was 11% and how the current KDPI of 94% did not reflect the true quality of the kidney, and the kidney function and preimplantation biopsy were very good. Virtual crossmatch results with both primary and secondary donors and how we were unable to do a formal crossmatch with the primary donor were discussed. We did complete the assessment of the kidney on the back table after dissecting the vessels and ureter before bringing the recipient in the operating room. We discussed the possibility of having to do a ureteroureterostomy or bladder mobilization if the ureter length was found to be short during the transplant. Risk of potential infection transmission from the donor was also discussed, we discussed that donor CMV IgM was negative, and therefore, CMV transmission would be unlikely but other infections like BK virus infection can happen and risk for that is unknown. The patient provided informed, written consent for transplant.

Fig. 2.

Final back table.

Fig. 2.

Final back table.

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The kidney was transplanted in a standard manner in the left iliac fossa of the recipient. Left iliac fossa was used due to peritoneal dialysis catheter exiting in the right iliac fossa. Interestingly, the bladder cuff was noted to be perfused by the kidney. The ureter length was felt to be adequate for anastomosis, and therefore, the bladder cuff was excised and standard Lich-Gregoir ureteroneocystostomy was done. The kidney reperfused very well (Fig. 3) and had excellent primary graft function thereafter. Induction immunosuppression was with basiliximab, tacrolimus XR, mycophenolate sodium, and prednisone for maintenance immunosuppression. The creatinine was stable at 1.4, 1.5 years after transplant. The recipient did develop early low-load BK viremia, but that has not affected the kidney function.

Fig. 3.

Kidney after reperfusion.

Fig. 3.

Kidney after reperfusion.

Close modal

Given the growing kidney transplant waitlist and shortage of available organs, there is a need to consider unconventional organ sources. One of them is utilizing transplanted organs and retransplanting them, in other words, recycling organs. Veale et al. [14] looked at the period between 2005 and 2014 in the USA and showed that every decade, about 20–25% of kidney recipients died with a functioning allograft. West et al. [18] found out that 22% of kidney recipients who die with functioning grafts succumb to infection, 17% from myocardial infarction, 15% from sudden death, and 10% from cancer. While the patients with cancer or infection might not be suitable candidates for kidney recycling/retransplantation, a lot of these kidney recipients can be potential donors.

The clinical worry with retransplantation is additional hits to the transplanted kidney with repeat death events, cold ischemia times, and ischemia-reperfusion injuries. Surgeons also worry about adhesions around the transplanted kidney, shorter vessels and ureter, and inability of blood and cells from the first donor for a physical flow crossmatch.

The first case of regrafting an explanted transplant kidney was reported by Al-Hasani et al. [19] in 1987. Since then, there are scant data in the literature about retransplanting organs (Table 1) A query of the Eurotransplant database over two decades showed just 4 cases of retransplantation [15]. Successful retransplantation has been demonstrated in varying scenarios – early retransplant due to death of the primary recipient [5, 9, 13, 14, 19], early retransplant due to primary recipient developing FSGS [6, 14] or TMA in the allograft [20], and retransplantation years after initial transplant [4, 7, 8, 10, 11, 14, 15], longest reported to be 9 years after initial transplant by Ghinea et al. [4].

We could find 4 reports of long-term follow-up and survival of retransplanted allografts [8, 10, 11, 15]. All these reports show excellent kidney allograft function in the secondary recipient even though all these recycled kidneys had been in the primary recipients for years before retransplantation, longest survival reported being 14 years post-retransplant by Goralczyk et al. [8].

All three recycled kidneys with either early recurrent FSGS or TMA [6, 14, 20] were from living secondary donors and had good function in the secondary recipients with resolution of proteinuria and improvement in histologic changes. There are some important considerations that need to be looked at while evaluating these offers and for a successful retransplant.

Procurement

It is easier to procure intraperitoneally placed kidneys due to less adhesions, but it is certainly possible to safely procure and transplant retroperitoneal kidneys too. Tips and tricks for procurement include cannulating the contralateral iliac artery and not the aorta to make sure the kidney gets adequately flushed. Another option is to cannulate the distal aorta as per normal procurement technique but also separately cannulating the iliac artery to flush the kidney. Another option described by Ghinea et al. [4] is cannulating the ipsilateral femoral artery for flushing with clamping of the distal aorta. The dissection and cannulation should be planned before the procurement. It is important to take the kidney out en bloc with surrounding muscle, soft tissue, and a good length of iliac vessels like in our case instead of trying to dissect the renal vessels in situ. The dissection of renal vessels is better done on the back table during the recipient case. The ureter should also be dissected along with surrounding soft tissue, and dissection should right till the bladder and take a cuff of the bladder as well to give the maximum possible ureter length during the recipient operation. A back table flush via the iliac artery after procurement can be considered to make sure the kidney is flushed appropriately. It is important to emphasize that such procurements should be done by experienced procurement surgeons due to anticipated technical difficulties.

Recipient Back Table

It is helpful to know the anatomy of the kidney from the primary donor procurement, whether there were single or multiple vessels/ureters. Meticulous dissection of the vessels needs to be done on back table. Keep the bladder cuff in case ureter is short for the recipient.

Recipient Choice

It is important to have a recipient with good bladder capacity given the short length of ureter. At least two PRA samples should be available to run a virtual crossmatch with both primary and secondary donors.

Information about the primary donor should be available, including anatomy of the transplant kidney and HLA profile of that donor to run virtual crossmatch with the eventual recipient. The role of virtual crossmatch in kidney recycling has been shown by other authors [10, 12, 17].

Transplant Procedure

The kidney should be placed relatively lower on the iliac vessels to make sure the short ureter easily reaches the bladder. In certain cases, the bladder might need to be mobilized or considered given to a ureteroureterostomy [8]. We still prefer to do a standard ureteroneocystostomy but if bladder cuff reperfuses well and ureter length is short and unable to reach, the bladder patch can be used. We separated the renal artery and vein from the primary recipient’s iliac vessels on the back table, but Veale et al. [14] have reported another approach of using the distal external iliac artery from the primary recipient for vascular anastomoses. Our concern with that approach is the quality of primary recipient’s external iliac vessels. Since our primary recipient was a long-term diabetic, his iliac artery had significant plaque precluding its use for implantation.

Immunosuppression Choice

Lugo-Baruqui et al. [10] reported excellent long-term outcome using sirolimus for maintenance immunosuppression after using a kidney allograft with known calcineurin inhibitor (CNI) toxicity changes on preimplantation biopsy. We followed our standard immunosuppression protocol with IL-2 inhibitor induction (for recipients >65 yo and not sensitized) along with triple maintenance immunosuppression. There were no chronic CNI toxicity changes noted on our preimplantation biopsy, and the primary donor was quite young with a healthy kidney.

Given our finding of early BK viremia in our patient, checking BK virus by PCR should be considered more frequently in the recipient. There have been two other case reports of viral transmission after reusing kidney allografts. Kadambi et al. [5] reported early ganciclovir-resistant CMV infection (within the first month of transplant) in the recipient, which was thought to be transmitted from the second donor who had a history of CMV infection in the past but was CMV IgM negative at the time of donation. The recipient had a good response to Foscarnet and was reported to have good allograft function 5 years posttransplant. Setyapranata et al. [9] reported a case of early HSV transmission after kidney retransplant which was successfully treated with good short-term outcome 9 months posttransplant. Therefore, thorough history and testing of the primary recipient is warranted at the time of donation. Early testing of the secondary recipient should also be considered, especially if primary recipient is known to have a history of a specific viral infection.

Another thing to remember is that the KDPI of the secondary donor/primary recipient is often not predictive of the kidney quality [14]. In our case, the reported KDPI of this kidney was 94% due to history of diabetes and hypertension in the primary recipient, as opposed to a KDPI of 11% of the original kidney. The KDPI of such kidneys should be ignored, and decision should be made based on kidney function, age, and KDPI of the original donor and kidney biopsy. We feel a kidney biopsy should be done for all recycled kidneys before implantation to assess chronic changes including CNI toxicity, BK nephropathy, rejection, FSGS, or TMA. This provides a baseline for pathology and helps guide immunosuppression, further testing, and follow-up biopsies. In conclusion, kidney recycling is a feasible option to increase availability of organs for transplant and help alleviate the problems of a long waitlist.

The patient provided informed, written consent to participate in the study and for publication of the information presented in this manuscript. Ethical approval is not required for this study in accordance with local or national guidelines.

The authors have no conflicts of interest to declare.

The study was not supported by any sponsor or funder.

T.B. – review of literature and introduction. P.S., M.R., J.R., O.E., D.M., D.K., S.R., A.G., D.I., and J.F. – critical review. K.Y. – conception and writing the manuscript.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.

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